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1793International Journal of Collaborative Research on Internal Medicine & Public HealthSeptation of the Sphenoid Sinus and its ClinicalSignificanceEldan Kapur 1*, Adnan Kapidžić 2, Amela Kulenović 1, Lana Sarajlić 2, Adis Šahinović 2,Maida Šahinović 31Department of anatomy, Medical faculty, University of Sarajevo, Čekaluša 90, 71000 Sarajevo, Bosniaand Herzegovina2Clinic for otorhinolaryngology, Clinical centre University of Sarajevo, Bolnička 25, 71000 Sarajevo,Bosnia and Herzegovina3Department of histology and embriology, Medical faculty, University of Sarajevo, Čekaluša 90, 71000Sarajevo, Bosnia and Herzegovina* Corresponding Author: Eldan Kapur, MD, PhDDepartment of anatomy, Medical faculty, University of Sarajevo, Bosnia and HerzegovinaEmail: eldan kapur@hotmail.comPhone: 033 66 55 49; 033 22 64 78 (ext. 136)AbstractIntroduction: Sphenoid sinus is located in the body of sphenoid, closed with a thin plate ofbone tissue that separates it from the important structures such as the optic nerve, opticchiasm, cavernous sinus, pituitary gland, and internal carotid artery. It is divided by one ormore vertical septa that are often asymmetric. Because of its location and the relationshipswith important neurovascular and glandular structures, sphenoid sinus represents a greatdiagnostic and therapeutic challenge.Aim: The aim of this study was to assess the septation of the sphenoid sinus and relationshipbetween the number and position of septa and internal carotid artery in the adult BHpopulation.Participants and Methods: A retrospective study of the CT analysis of the paranasal sinusesin 200 patients (104 male, 96 female) were performed using Siemens Somatom Art with thefollowing parameters: 130 mAs: 120 kV, Slice: 3 mm. For the coronal scan, patients wereplaced in supine position with their chin hyper extended and scan plane angled such that itwas as perpendicular to the hard palate. Scanning was completed from the anterior frontalsinus to the sphenoid sinus. Axial scans were performed from the maxillary sinus floor to thelevel of the frontal sinus roof, in a plane parallel with the hard palate. Since the aim of thisstudy was to evaluate anatomical variations of sphenoid sinus septation, only patients with nodiseases within sphenoid sinus were included.Results: Based on analysis of CT scans of patients we come to the conclusion of existencemore than 1 sphenoid septum in 32% of male patients and 22.1% of female patients. In total,Vol. 4 No. 10 (2012)

1794International Journal of Collaborative Research on Internal Medicine & Public Healthtying for the septum to the carotid canal at posterolateral wall of sinus was registered in 19.4%of male, and 16.8% female patients.Conclusion: Performing CT of paranasal sinuses before surgery is essential to avoid potentialcomplications resulting from anatomical variations.Keywords: sphenoid sinus, septation, computed tomographyIntroductionSphenoid sinus is located in the body of sphenoid bone, closed with a thin plate of bone tissuethat separates it from the surrounding important structures such as the optic nerve, opticchiasm, cavernous sinus, pituitary gland, and internal carotid artery. It is divided by one ormore vertical septa that are often asymmetric. Because of its location and the previouslymentioned relationships with important neurovascular and glandular structures, sphenoid sinusrepresents a great diagnostic and therapeutic challenge.1 Knowing and visualization of theserelationships, and possibly present variations in this area is the key to successful surgicalapproach to these elements, as well as appropriate functional endoscopic procedures.2 Toperform high quality and safe functional endoscopic sinus surgery for the removal ofpathological tissue changes, preoperative preparation and adequate diagnosis (primarilycomputed tomography and magnetic resonance imaging) is essential.3CT is becoming the gold standard in the preoperative evaluation of patients with plannedsurgical removal of pituitary tumors by transsphenoidal approach.4,5 Today over 95% ofpituitary tumors are removed in this way. Natural free spaces of the nasal cavity and sphenoidsinus are used to access the center of the base of the skull, in sella turcica, and then in thewider perisellar region with minimal surgical trauma. It is important to note, that in this microneurosurgical intervention, both holes of sphenoid sinus must be show and after that frontalwall of the sinus along with rostrum is being resected. Sinus septum, which is often locatedlateral of sagittal plane and the sphenoid sinus mucosa, is being removed. After a goodpreparation and inspection, sphenoid sinus as well as bottom of sella turcica is being shownand after their detailed inspection it approaches opening of sella turcica by microsurgicalinstruments. Various modifications and expanded transsphenoidal approach allow removal oftumors that grow beyond the sella turcica and suprasellar region. Approach can be extendedsuperiorly for resection of suprasellar lesion, inferiorly for resection of the clivus lesion andlaterally for the cavernous sinus lesions.6The sphenoid septum is an important landmark during the endonasal endoscopictranssphenoidal approach to important structures such as the carotid artery, optic canal, andskull base.6,7 Although there are several reports about the sphenoid sinus, none has beencarried out in our country. Due to the large anatomical variations of the sphenoid sinus, it iscrucial to know in detail about its septation in order to safely perform the endoscopicapproaches, and even more so in an environment where intra-operative neuronavigation isabsent.8Vol. 4 No. 10 (2012)

1795International Journal of Collaborative Research on Internal Medicine & Public HealthThe objecive of this study was to access the septation of the sphenoid sinuses, as well as therelationship between these septa and bony wall cover of internal carotid artery in adult BHpopulation.Participants and methodsA retrospective study was done on 200 patients at Clinical Centre University of Sarajevo.There were 104 males and 96 females, with an age range of 20 to 74 years (males, 48.6 14.7yrs; females, 49.9 17.9 yrs). The study excluded patients younger than 16 years, and patientswho have had sinus operations, patients with head and neck trauma, and patients with tumorsand polyps of the nasal cavity and paranasal sinuses.CT images were made on the CT scanner SOMATOM ART SIEMENS (130 kV, 120 mAs), 3mm thickness and an image matrix 512X512. Scans were done in both axial and coronalplane, with identical fields of view. For the coronal scan, patients were placed in supineposition with their chin hyper extended and scan plane angled such that it was asperpendicular to the hard palate. Scanning was completed from the anterior frontal sinus to thesphenoid sinus. Axial scans were performed from the maxillary sinus floor to the level of thefrontal sinus roof, in a plane parallel with the hard palate. Images were reviewed on theconsole with varying window levels and widths. The sphenoid sinuses were reviewed in bothaxial and coronal planes, and the total number of septa were counted (main and accessory) andcompared in both planes. The data were processed by computer software’s DICOM WORKS1.3.5. (Digital Imaging and Communication in Medicine) SANTE DICOM VIEWER andOZIRIS 4.ResultsBy analysis of CT images of patients of the Clinic of Radiology of Clinical Centre Universityof Sarajevo it is found that only 2 (2%) had no septum within the sphenoid sinus, one maleand one female. Other respondents (98%) possessed the so-called intersphenoid septum.Only one so-called intersphenoid or how we also defined it the main septum had 70 (68%)men. By analysis of axial CT images of male respondents was found that the main septumexists in 87 (84.5%) (from the 103 men with the existence of one or more septa) had not beenplaced in the median line, at its posterior point, but paramedially, on the left or right side. Ofthe 87 analyzed images of men, the right-set intersphenoid septum had 56 (64.4%), and leftset 31 (35.6%).From the 103 male patients who had verified existence of intersphenoid septum, 20 of them(19.4%) had one more so-called accessory septa, a total of two in one sphenoid sinus. Of the20 people who had registered the existence of accessory septum, in 13 cases, accessoryseptum was located to the right of the so-called main septum, and in 7 cases left of it.Vol. 4 No. 10 (2012)

1796International Journal of Collaborative Research on Internal Medicine & Public HealthPresence of 3 septa (1 main, 2 accessory) in male patients was found in 8 (7.8%) patients. In 5cases one septum was located to the right and left of the so-called main intersphenoid septum,in 2 cases each additional septum was to the right from the main one, and in one case left fromthe main septum.The existence of sphenoid sinuses with 4 septa (1 main and 3 accessory) was registered in 5(4.8%) male patients. Schedule was as follows: in 3 cases - 2 right, 1 left from the so-calledmain septum, in 1 case-2 left, 1 right of the main septum (Figure 1), and in 1 case all 3accessory septa were located to the right of the main septum.Based on analysis of CT scans of male patients we come to the conclusion of existence morethan 1 sphenoid septum in the sinus in 33 cases (32%). All the above data refer to the sampleof 103 male individuals, since in one case it had not been registerated existence of a septum.Figure 1: Axial CT head scan of male patient (38 year-old)Visible existence of multiple septa in the sphenoid sinusIn addition to the analysis of the number of septa, in this paper special emphasis is placed totheir insertion, primarily in relation to the carotid canal on posterolateral wall of sphenoidsinus. In men with the existence of one septum it is established it’s insertion in the projectionof the carotid canal, one on the right and one on the left. From 20 men with the existence of anaccessory septa, it’s insertion in the carotid canal was visualized in 10 cases, 6 left and 4 right(Figures 2 and 3). In cases of two accessory septa (8 men), it has been noted their startingpoint in the projection of the carotid canal in 5 patients, 3 right, 2 left. In men with 3 accessorysepta it has been registered their association with carotid canal in all cases, 3 right and 2 left.In total, tying for the septum to the carotid canal at posterolateral wall of sphenoid sinus wasregistered in 22 men or (19.4%) of cases.Vol. 4 No. 10 (2012)